STUDENTS

Submit the form below. (Grades 3-12 only)
We will contact you to set up an interview with the student participating and parents/guardian.
Notification of acceptance to program and orientation.

STUDENT REGISTRATION FORM

Student Name

First Name

Last Name

Parent or Guardian Name (with whom the student lives)

First Name

Last Name

Student Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Home Phone Number

(###)

###

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Student Email Address

Parent/Guardian Email Address

Parent/Guardian Phone Number

(###)

###

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School Student Attends

List five subjects you or your student would like assistance in (e.g. Reading, Writing, Math, etc.)

What organizations/clubs do you or your student belong to or participate in at school, church, or in the community?

Student: Please list five areas of career interest and list them in order of preference (e.g. Teacher, Accountant, Doctor, etc.)

What day are you and your student available to visit The Center?

MM

DD

YYYY